Maternal morbidity associated with skin incision type at cesarean delivery in obese patients: a systematic review.

AIM: To describe the relationship between cesarean skin incision type and postoperative wound complications (WCs) in obese pregnant patients. MATERIALS & METHODS: MEDLINE (PubMed and OVID), Embase, Scopus, Web of Science Core Collection, Cochrane Library and ClinicalTrials.gov databases were used for publication search. Selection criteria consisted of articles studying pregnant patients with BMI ≥30 kg/m2 undergoing cesarean delivery and assessing the effect of skin incision type on postoperative maternal outcomes. RESULTS: Ten publications met criteria for a systematic review of a total of 2946 patients. The transverse skin incision was associated with a lower rate of WC compared with the vertical skin incision. The pooled risk ratio for WCs was 0.47 (95% CI: 0.37-0.58; p < 0.00001). CONCLUSION: Transverse skin incision may be preferable to vertical skin incision at cesarean delivery in pregnant patients with obesity as it may be associated with a lower rate of WCs.PROSPERO registration ID: CRD42020151106.

The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature.

As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.

Maternal Obesity Is an Independent Risk Factor for Intensive Care Unit Admission during Delivery Hospitalization.

OBJECTIVE: We aim to quantify the impact of obesity on maternal intensive care unit (ICU) admission. MATERIALS AND METHODS: This is a population-based, retrospective cohort study of Ohio live births from 2006 to 2012. The primary outcome was maternal ICU admission. The primary exposure was maternal body mass index (BMI). Relative risk (RR) of ICU admission was calculated by BMI category. Multivariate logistic regression quantified the risk of obesity on ICU admission after adjustment for coexisting factors. RESULTS: This study includes 999,437 births, with peripartum maternal ICU admission rate of 1.10 per 1,000. ICU admission rate for BMI 30 to 39.9 kg/m2 was 1.24 per 1,000, RR: 1.20 (95% confidence interval [CI]: 1.07, 1.35); BMI 40 to 49.9 kg/m2 had ICU admission rate of 1.80 per 1,000, RR: 1.73 (95% CI: 1.38, 2.17); and BMI ≥ 50 kg/m2 had ICU admission rate of 2.98 per 1,000, RR: 1.73 (95% CI: 1.77, 4.68). After adjustment, these increases persisted in women with BMI 40 to 49.9 kg/m2 with adjusted relative risk (adjRR) of 1.37 (95% CI: 1.05, 1.78) and in women with BMI ≥ 50 kg/m2, adjRR: 1.69 (95% CI: 1.01, 2.83). CONCLUSION: Obesity is a risk factor for maternal ICU admission. Risk increases with BMI. After adjustment, BMI ≥ 40 kg/m2 is an independent risk factor for ICU admission.

Atrial Fibrillation as a Rare Complication of the Use of Nifedipine as a Tocolytic Agent: A Case Report and Review of the Literature.

Calcium channel blockers are commonly used tocolytic agents on Labor and Delivery units worldwide as part of the management of preterm labor. Despite their overall reassuring safety profile, rare cardiovascular complications have been reported. In this report, we describe the case of threatened preterm labor managed with nifedipine with subsequent development of atrial fibrillation. This type of cardiac arrhythmia may have considerable consequences for both the mother and the fetus. The aim of this case report and comprehensive review of the literature is to raise awareness.

Use of an Amnioport to Maintain Amniotic Fluid Volume in Fetuses with Oligohydramnios Secondary to Lower Urinary Tract Obstruction or Fetal Renal Anomalies.

OBJECTIVE: We describe a technique to maintain amniotic fluid in fetuses with severe oligo-/anhydramnios secondary to lower urinary tract obstruction or fetal renal disease when urine production is inadequate to maintain a normal amniotic fluid volume (AFV). METHODS: An amnioport was inserted into the amniotic space. The catheter was secured to prevent dislodgment and tunneled to a subcutaneous reservoir. The reservoir was accessed as necessary, infusing normal saline to maintain AFV. Pregnancy continued until term or indicated delivery. RESULTS: Since 2010, 15 patients in this category were considered for an amnioport. Six chose comfort care and one elected percutaneous amnioinfusions. Nine amnioport procedures were performed in eight patients. There were no fetal deaths. All eight had successful restoration and maintenance of amniotic fluid. Delivery ranged from 9 to 96 days after placement (mean 63.7 days). One died due to unrecognized laryngeal web and another one died of pulmonary hypoplasia after preterm premature rupture of membranes. None of the remaining six had pulmonary hypoplasia. Three remain alive. DISCUSSION: Severe oligo-/anhydramnios in the second trimester secondary to fetal anomalies is almost uniformly lethal due to pulmonary hypoplasia without restoration of amniotic fluid. The amnioport procedure may allow pulmonary survival but commits families to postnatal care decisions regarding pulmonary and renal complications.

Relationship of trimester-specific smoking patterns and risk of preterm birth.

BACKGROUND: In 2011, the US national rate of smoking early in pregnancy was 11.5%. Unfortunately, our home state of Ohio had a rate twice as high at 23%. Smoking in pregnancy remains one of the most important modifiable risk factors for pregnancy complications, specifically preterm birth. OBJECTIVE: The objective of the study was to quantify the preterm birth risk to various trimester-specific smoking behaviors. STUDY DESIGN: The study was a population-based, retrospective cohort study of singleton non-anomalous live births, using Ohio birth records 2006 to 2012. Preterm birth rates were compared between non-smokers and women who smoked in the preconception period only, those who quit smoking after the 1st and 2nd trimesters, and those who smoked throughout pregnancy. Multivariate logistic regression quantified the risk of smoking with cessation at various times in pregnancy and preterm birth risk, adjusted for maternal race, education, age, Medicaid use, marital status, and parity. A stratified analysis was performed on the basis of preterm birth subtype: spontaneous preterm birth versus indicated preterm birth. We also performed an additional analysis stratifying for maternal race using the 2 largest categories of race (non-Hispanic white and non-Hispanic black). RESULTS: Of the 913,757 birth records analyzed, nearly 25% of the women reported some smoking behavior on the birth certificate data. Of smokers, less than half quit during pregnancy (38.8% vs 61.2% smoked throughout pregnancy). Early quitters had a similar preterm birth rate compared with non-smokers. Women who smoked through the 1st trimester only did not have a significant increase in their overall preterm birth odds ratio <37 weeks; however, it did increase the odds of extreme preterm birth <28 weeks by 20% (adjusted odds ratio, 1.20; 95% confidence interval [CI], 1.02, 1.40). Quitting late in pregnancy resulted in the highest odds ratio increase: 70% for preterm birth <37 weeks (adjusted odds ratio 1.70; CI, 1.60, 1.80), even after adjustment for the confounding influences. Quitting smoking early in pregnancy after the 1st trimester did not increase the overall risk of spontaneous or indicated preterm birth <37 weeks significantly. However, quitting after the 1st trimester was associated with a significant increase in risk of extreme spontaneous preterm birth <28 weeks, an effect not seen with indicated preterm birth <28 weeks. Delaying cessation until late in pregnancy-after the 2nd trimester-was associated with the highest risk increases, 65% increased odds of spontaneous and 78% increase in odds of indicated preterm births. The rate of preterm births to non-Hispanic black mothers was increased in all categories over those of non-Hispanic white mothers. The relative influence of smoking cessation in pregnancy was similar in black compared with white mothers. The effect modification in the regression model was analyzed and revealed no significant interaction between race and smoking patterns on preterm birth risk. CONCLUSION: Smoking throughout pregnancy is associated with an increased risk of preterm birth. However, quitting early in pregnancy negates this risk. Widespread programs aimed at smoking cessation early in pregnancy could have a significant impact on reducing the rate of preterm birth nationally.

Factors Associated with Smoking Cessation in Pregnancy.

Objective The objective of this study was to quantify the influence of various patient characteristics on early smoking cessation to better identify target populations for focused counseling and interventions. Study Design This study was a population-based retrospective cohort study of 1,003,532 Ohio live births more than 7 years (2006-2012). Women who quit smoking in the first trimester were compared with those who smoked throughout pregnancy. Logistic regression estimated the strength of association between patient factors and smoking cessation. Results The factors most strongly associated with early smoking cessation were non-white race and Hispanic ethnicity, at least some college education, early prenatal care, marriage, and breastfeeding. Numerous factors commonly associated with adverse perinatal outcomes were found to have a negative association with smoking cessation: low educational attainment, limited or late prenatal care, prior preterm birth, age < 20 years, age ≥ 35 years, and indicators of low SES. In addition, the heaviest smokers (≥ 20 cigarette/day) were least likely to quit (adjusted relative risk [RR], 0.35; 95% confidence interval 0.34, 0.36). Conclusion Early prenatal care and initiation of breastfeeding before discharge from the hospital are associated with increased RR of quitting early in pregnancy by 52 and 99%, respectively. Public health initiatives and interventions should focus on the importance of early access to prenatal care and education regarding smoking cessation for these particularly vulnerable groups of women who are at inherently high risk of pregnancy complications.

Association of reported trimester-specific smoking cessation with fetal growth restriction.

OBJECTIVE: To assess the association of reported smoking cessation at various time points during pregnancy with fetal growth restriction. METHODS: This was a population-based retrospective cohort study of singleton nonanomalous live births using Ohio birth certificates, 2006-2012. Outcomes of women who reported smoking only in the 3 months before conception and women who reported smoking through the first, second, or third trimester were compared with a referent group of nonsmokers. Multivariate logistic regression assessed the association between smoking cessation at various times in pregnancy and fetal growth restriction less than the 10th and 5th percentiles. RESULTS: Of 927,424 births analyzed, 75% of mothers did not smoke. Of smokers, 24% smoked preconception only, 10% quit after the first trimester, 4% quit after the second trimester, and 59% smoked throughout pregnancy. The rate of fetal growth restriction less than the 10th and 5th percentiles among nonsmokers was 8.1% and 3.6%, respectively. Although smoking only in the preconception period did not significantly increase fetal growth restriction risk, smoking in any trimester did. The adjusted odds ratio (95% confidence interval) for fetal growth restriction less than the 10th and 5th percentiles, respectively, of cessation after the first trimester was 1.19 (1.13-1.24) and 1.25 (1.17-1.33) and 1.67 (1.57-1.78) and 1.83 (1.68, 1.99) for cessation after the second trimester. Women who reported smoking throughout pregnancy had the highest risks of fetal growth restriction, 2.26 (2.22-2.31) and 2.44 (2.37-2.51), after accounting for the influence of race, low socioeconomic status, and medical comorbidities. CONCLUSION: Smoking of any duration during pregnancy is associated with an increased risk of fetal growth restriction with decreasing risk the earlier that cessation occurs. Smoking cessation programs should focus on the benefit of quitting as early in pregnancy as possible. LEVEL OF EVIDENCE: II.

Giant chorioangiomas: perinatal outcomes and techniques in fetoscopic devascularization.

OBJECTIVE: To evaluate the intrauterine management and perinatal outcome of pregnancies complicated by giant placental chorioangioma (>4 cm) and elaborate on various devascularization techniques. MATERIALS AND METHODS: Retrospective review of 10 cases of giant placental chorioangioma evaluated between January 2005 and August 2012. Maternal demographics, prenatal imaging, response to fetoscopic treatment, obstetrical complications, and perinatal outcomes were evaluated. RESULTS: Overall survival was 80%. Seven (70%) cases were associated with obstetrical complications, including polyhydramnios (n = 7), non-immune hydrops (n = 3), and high cardiac output state (n = 5). Five patients underwent fetoscopic devascularization at a mean gestational age of 24.03 weeks with 80% survival. The tumors were devascularized by bipolar coagulation (n = 1), combination of bipolar and diode laser (n = 2), bipolar and radiofrequency ablation (n = 1), and surgical clip application (n = 1). Postoperatively, all survivors had resolution of hydrops and high cardiac output states with survival beyond 60 days of life. DISCUSSION: Fetoscopic devascularization is indicated for high cardiac output states or non-immune hydrops and may require multiple techniques including bipolar coagulation, clip application, and/or laser to interrupt arterial inflow and devascularize the mass.

Acute kidney injury during pregnancy.

Acute kidney injury complicates the care of a relatively small number of pregnant and postpartum women. Several pregnancy-related disorders such as preeclampsia and thrombotic microangiopathies may produce acute kidney injury. Prerenal azotemia is another common cause of acute kidney injury in pregnancy. This manuscript will review pregnancy-associated acute kidney injury from a renal functional perspective. Pathophysiology of acute kidney injury will be reviewed. Specific conditions causing acute kidney injury and treatments will be compared.

Design considerations for point-of-care clinical trials comparing methadone and buprenorphine treatment for opioid dependence in pregnancy and for neonatal abstinence syndrome.

RATIONALE: In recent years, the U.S. has experienced a significant increase in the prevalence of pregnant opioid-dependent women and of neonatal abstinence syndrome (NAS), which is caused by withdrawal from in-utero drug exposure. While methadone-maintenance currently is the standard of care for opioid dependence during pregnancy, research suggests that buprenorphine-maintenance may be associated with shorter infant hospital lengths of stay (LOS) relative to methadone-maintenance. There is no "gold standard" treatment for NAS but there is evidence that buprenorphine, relative to morphine or methadone, treatment may reduce LOS and length of treatment. DESIGN: Point-of-care clinical trial (POCCT) designs, maximizing external validity while reducing cost and complexity associated with classic randomized clinical trials, were selected for two planned trials to compare methadone to buprenorphine treatment for opioid dependence during pregnancy and for NAS. This paper describes design considerations for the Medication-assisted treatment for Opioid-dependent expecting Mothers (MOMs; estimated N = 370) and Investigation of Narcotics for Ameliorating Neonatal abstinence syndrome on Time in hospital (INFANTs; estimated N = 284) POCCTs, both of which are randomized, intent-to-treat, two-group trials. Outcomes would be obtained from participants' electronic health record at three participating hospitals. Additionally, a subset of infants in the INFANTs POCCT would be from mothers in the MOMs POCCT and, thus, potential interaction between medication treatment of mother and infant could be evaluated. CONCLUSION: This pair of planned POCCTs would evaluate the comparative effectiveness of treatments for opioid dependence during pregnancy and for NAS. The results could have a significant impact on practice.

Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage.

OBJECTIVE: When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony. STUDY DESIGN: These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb). RESULTS: A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding. CONCLUSION: We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation.

Risk factors for a prolonged length of stay in women hospitalized for preeclampsia in Texas.

OBJECTIVES: To identify correlates of a prolonged length of stay (PLOS) in women hospitalized for preeclampsia/eclampsia in Texas, USA. METHODS: Statewide hospital data were obtained, and the records of women who were discharged in 2004 and/or 2005 with a principal discharge diagnosis of preeclampsia or eclampsia were extracted using ICD-9-CM codes. PLOS was defined as a stay greater than 5 days. Odds ratios (OR) for PLOS were calculated. Generalized estimating equations were used to account for a small group of women who were hospitalized multiple times during the study period for preeclampsia. A total of 21,203 records were analyzed. RESULTS: The crude incidence of PLOS was 17.5%. Advancing maternal age was positively associated with PLOS: for every 10-year increase, there was a 20% increase in the odds of PLOS (adjusted OR = 1.20,95% confidence interval (CI): 1.13, 1.28). The strongest risk factor for PLOS was the presence of renal disease: adjusted OR 5.81 (95% CI: 3.97, 8.50). Protective factors included Medicaid beneficiary status, and being admitted from the emergency department. CONCLUSIONS: The strongest correlate of PLOS in a large cohort of women hospitalized for preeclampsia was the presence of renal disease.

Bell's palsy and pregnancy.

OBJECTIVE: To describe the epidemiology, pathophysiology, presentation, treatment, and prognosis of Bell's palsy (BP) in pregnancy. RESULTS: The incidence of BP in pregnant women is not significantly greater than expected compared to all women of childbearing age. There is a high incidence of cases in the third trimester and corresponding low incidence during early pregnancy. CONCLUSION: There is no conclusive evidence that the etiology of BP in pregnancy is different than in nonpregnant patients. Altered susceptibility to herpes simplex viral reactivation during pregnancy is the most likely explanation for concentration of cases in the third trimester. Outcome may be poorer in pregnant patients, though historically, treatment is often withheld from these patients. SIGNIFICANCE: Management of BP in pregnancy can mirror that of nonpregnant individuals with the exception of first-trimester cases.

Detection of gestational diabetes mellitus by homeostatic indices of insulin sensitivity: a preliminary study.

OBJECTIVE: We investigated whether homeostatic indices of insulin sensitivity might suitably screen for gestational diabetes mellitus. STUDY DESIGN: One hundred twenty-three pregnant women who were between 24 and 28 weeks of gestation completed a 3-hour 100-g oral glucose challenge test and fasting insulin level in a nested case-control study design. Insulin sensitivity indices were calculated and tested for their ability to detect gestational diabetes mellitus. RESULTS: Fasting glucose demonstrated the best overall accuracy, but the homeostasis model assessment and quick insulin sensitivity check index were also sensitive screening techniques for gestational diabetes mellitus when either the National Diabetes Data Group or Carpenter-Coustan criteria were used. CONCLUSION: Homeostasis model assessment, quick insulin sensitivity check index, and fasting glucose are sensitive screening tests for gestational diabetes mellitus and can avoid oral administration of glucose-containing solutions.

Getting the right cells to the array: Gene expression microarray analysis of cell mixtures and sorted cells.

BACKGROUND: Most biological samples are cell mixtures. Some basic questions are still unanswered about analyzing these heterogeneous samples using gene expression microarray technology (MAT). How meaningful is a cell mixture's overall gene expression profile (GEP)? Is it necessary to purify the cells of interest before microarray analysis, and how much purity is needed? How much does the purification itself distort the GEP, and how well can the GEP of a small cell subset be recovered? METHODS: Model cell mixtures with different cell ratios were analyzed by both spotted and Affymetrix MAT. GEP distortion during cell purification and GEPs of purified cells were studied. CD34+ cord blood cells were purified and analyzed by MAT. RESULTS: GEPs for mixed cell populations were found to mirror the cell ratios in the mixture. Over 75% pure samples were indistinguishable from pure cells by their overall GEP. Cell purification preserved the GEP. The GEPs of small cell subsets could be accurately recovered by cell sorting both from model cell mixtures and from cord blood. CONCLUSIONS: Purification of small cell subsets from a mixture prior to MAT is necessary for meaningful results. Even completely hidden GEPs of small cell subpopulations can be recovered by cell sorting.

Neonatal organ system injury in acute birth asphyxia sufficient to result in neonatal encephalopathy.

OBJECTIVE: To identify the proportion of major organ system injury in cases of acute intrapartum asphyxia that result in neonatal encephalopathy. METHODS: A prospectively maintained database was cross-referenced using medical record coding to identify diagnoses of acute intrapartum asphyxia, acute birth asphyxia, or neonatal encephalopathy over a 6-year period. An acute intrapartum asphyxial antecedent was validated with emphasis on excluding long-standing or chronic conditions where injury likely occurred before presentation. Injury pattern was evaluated using routinely available laboratory and imaging tests. RESULTS: Forty-six cases of acute peripartum asphyxia sufficient to result in the diagnosis of neonatal encephalopathy were identified. Clinical central nervous system injury resulting in encephalopathy was present in 100% of cases as it was an entry criteria; of these, 49% had electroencephalogram and 40% had imaging studies diagnostic of acute injury. Liver injury based on elevated aspartate transaminase or alanine transaminase levels occurred in 80%. Heart injury, as defined by pressor or volume support beyond 2 hours of life or elevated cardiac enzymes, occurred in 78%. Renal injury, defined by an elevation of serum creatinine to greater than 1.0 mg/dL, persistent hematuria, persistent proteinuria, or clinical oliguria, occurred in 72%. An elevation in nucleated red blood cell counts exceeding 26 per 100 white blood cells occurred in 41%. CONCLUSION: Using common diagnostic tests as markers of acute asphyxial injury, we noted that multiple organs suffer damage during an acute intrapartum asphyxial event sufficient to result in a neonatal encephalopathy.

Documentation of amniotic fluid embolism via lung histopathology. Fact or fiction?

OBJECTIVE: To evaluate pulmonary histopathology for confirming amniotic fluid embolism. STUDY DESIGN: The Capra hircus (goat) model with fresh, homologous amniotic fluid was used. Raw fluid (n = 8), fluid filtered through a 5-microns filter (n = 14) and meconium-stained fluid with 1-7% solid debris (n = 7) were injected. Three hours after embolization the animals were euthanized and specimens collected. Three to five areas of lung were sampled based on the most abnormal areas visually. Traditional and special stains were utilized. The study protocol was approved by the institutional review board and animal use and care committee. Statistical analysis was by chi 2 with Yates correction. Significance was defined as P < .05. RESULTS: Amniotic fluid debris (fetal squames, mucin or foreign pigments) was found in 10 of 29 animals (34.5%). Debris was found in 7/7 (100%) of the meconium group, 2/8 (25%) of the raw fluid group and 1/14 of the filtered group (7%). The likelihood of finding debris in amniotic fluid embolism with meconium-stained fluid was greater than with raw (P < .017) or filtered amniotic fluid (P < .001). CONCLUSION: In this animal model, histopathologic confirmation of amniotic fluid embolism was an unreliable marker of the event except in cases of amniotic fluid embolism involving meconium-stained fluid.